(Applicable to all Sponsored Project Proposals and other significant individual and
institutional conflicts of interest)

Name:

Name and relationship of Family Member with Conflict (if applicable):

Department/Unit:

School/Unit:

Proposal Submitted to (Sponsor):

Proposal Title:

A. Reason for Form: I am completing this form pursuant to one of the following:

_____ Institutional conflict of interest per Augusta University Institutional Conflicts
of Interest Policy;

_____ Annual disclosure as required by Augusta University Individual Conflicts of
Interest Policy;

_____ Update of my annual conflict of interest disclosure;

_____ In connection with my involvement as investigator in a proposal entitled:

where the sponsor is:

PLEASE READ THE FOLLOWING CAREFULLY: Check this item ONLY IF you have no

reportable significant financial or other possible conflicts of interest pursuant
to Augusta University Conflicts of Interest Policies.

_____ I HAVE NO SIGNIFICANT FINANCIAL OR OTHER SIGNIFICANT CONFLICT OF

INTEREST THAT I AM REQUIRED TO REPORT. If you check this item, then proceed to PART
E, complete that section and submit this form to your Department or Unit Supervisor
or Dean.

B. Type of Interest: I have read and understood the Conflicts of Interest Policies of Augusta University.
I am disclosing the following type of conflict of interest (check at least one) and
attaching supporting documentation (in an envelope marked confidential) that identifies
the business enterprise or entity involved and the nature and details of the interest:

1. Significant financial interest. Individual's significant financial interests are
defined as anything of monetary value, including, but not limited to, salary or other
payments for services (e.g., consulting fees or honoraria); equity interests (e.g.,
stocks, stock options or other ownership interest); and intellectual property rights
(e.g., patents, trademarks, copyrights and royalties from such rights). "Investigator"
includes Investigator and the Investigator's spouse or

dependent children. [See Augusta University Conflict of Interest Policy for items
not included.]

____ Salary or other payment for services (e.g., consulting fees or honoraria).

____ Other significant financial interest of the individual of family member that
possibly could affect or be perceived to affect the results of the research or other
scholarly activities funded or proposed for funding or other work on behalf of Augusta
University. This interest is described as follows: